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Surgical Technique ARTHROSCOPIC B A NK art L esio N repair Using the 3.5mm LactoScrew® Suture Anchor Surgical Technique Diagnostic Arthroscopy • Standard posterior portal (Figure 1) • Anterior/superior rotator interval portal placed just off anterior edge of acromion (more superior than usual) • Assess for . • Bankart lesion • Integrity of anterior / inferior ligaments (MGHL, IGHL, inferior pouch) – May be seen best with scope in anterior/superior portal – Intrasubstance tearing – HAGL • Hill-Sachs lesion or other articular injury • SLAP lesion • Biceps tendon integrity / stability • Articular surface rotator cuff tear Figure 1 Establish Anterior Bankart Lesion Trans-Subscapularis Portal View from Anterior Cannula • Be aware of axillary nerve position at medial / inferior border of subscapularis (Figure 2) • 2mm guide pin through muscular portion of subscapularis (below superior subscapularis tendon, mid-substance) • 7mm cannulated obturator +7mm cannula placed over guide pin Figure 2 Surgical Technique Anterior/Inferior Labral Debridement/ Bony Preparation (Figure 3) • Place 30° scope in anterior/superior portal or 70° scope in posterior portal to maximize visualization • Contour edges of torn labrum (conservative debridement) • Small, curved shaver (3.5mm) to debride anterior/inferior glenoid bone • Small burr (3.5mm) to decorticate anterior/inferior glenoid bone • Avoid deep trough • Avoid glenoid articular cartilage injury Placement of Suture Anchors Figure 3 • If utilizing 30° scope, place in anterior/superior portal to enable placement of suture anchor(s) under direct visualization • If utilizing 70° scope in posterior portal, probe may be placed in anterior/superior portal deviating labrum medially, exposing prepared anterior/inferior glenoid bone • Suture anchor(s) placed through anterior transsubscapularis portal • Place suture anchors right on articular margin (Figure 4) • Drill/tap to laser mark depth • LactoScrew® Suture Anchor placed to laser mark depth • Assess stability of anchor under direct visualization • Pull superior suture limbs through anterior/ superior cannula Figure 4 Placement of Suture Throught Labrum • Mini suture punch through anterior/superior portal, piercing labrum (Figure 5) • Retrieve suture limbs from anterior/superior cannula through anterior portal • Avoid suture crossing/tangling • Prepare for knot tying if single anchor is utilized Figure 5 If Second Suture is Desired • Retrieve previously placed anchor sutures from anterior portal through anterior/superior portal • Remove and replace anterior/superior cannula with sutures left outside this cannula (avoids entanglement of sutures) • Repeat steps of suture anchor placement and placement of suture through labrum (above) Knot Tying1 • Tie sutures from inferior anchor first, utilizing anterior transcapularis portal after retrieving from anterior/superior Figure 6 portal (Figure 6) • First two throws: should utilize suture through labrum as post • Second throw: two half-hitches, same direction, around desired post utilizing Nordt™ Knot Tightner • Third throw: half-hitch, opposite direction, alternate post (locking the knot) • Fourth throw: half-hitch, opposite direction, alternate post • Fifth throw: half-hitch, opposite direction, alternate post • Cut suture ends 1– 2mm above knot • Pull second suture ends from outside anterior/superior cannula through anterior portal • Repeat knot tying of superior anchor sutures (Figure 7) • Assess stability of repair Address Ligamentous Plastic Deformation if Present by… • Electrothermal capsulorrhaphy Figure 7 • Arthroscopic suture capsulorrhaphy 1. Connor PM, Milia M. Arthroscopic knot tying techniques: a critical assessment. J Arthroscopy, Submitted for publication, 2000. Developed in conjunction with Patrick M. Connor, M.D. and Donald F. D’Alessandro, M.D., Charlotte, North Carolina. Charlotte,™ LactoScrew® and Nordt™ are trademarks of Arthrotek, Inc. This brochure is presented to demonstrate the surgical technique utilized by Patrick M. Connor, M.D. and Donald F. D’Alessandro, M.D. Arthrotek, as the manufacturer of this device, does not practice medicine and does not recommend this or any other surgical technique for use on a specific patient. The surgeon who performs any procedure is responsible for determining and utilizing the appropriate techniques for such procedure for each individual patient. Arthrotek is not responsible for selection of the appropriate surgical technique to be Complete Assess for Stability utilized for an individual patient. This material is intended for the Arthrotek Sales Force and surgeons only. It is not intended to be redistributed without the express written consent of Arthrotek. Arthrotek, Inc. 01-50-1072 3. Patient conditions including: blood supply limitations, insufficient quantity or quality of bone, or latent A Wholly Owned Subsidiary of Biomet, Inc. Date: 02/05 infections. 56 East Bell Drive 4. Pathologic soft tissue conditions, which would prevent secure fixation. Warsaw, Indiana 46582 USA WARNINGS ® ARTHROTEK® SOFT TISSUE ANCHORING DEVICES Arthrotek internal fixation devices provide the surgeon with a means to aid in the management of soft ATTENTION OPERATING SURGEON tissue to bone reattachment procedures. While these devices are generally successful in attaining these goals, they cannot be expected to replace normal healthy soft tissue or withstand the stress placed upon the DESCRIPTION device by full or partial weight bearing or load bearing, particularly in the presence of incomplete healing. The Arthrotek® Soft Tissue Anchoring Devices are resorbable repair devices used to attach soft tissue to bone. Therefore, it is important that immobilization (use of external support, sling, etc.) of the treatment site be LactoSorb® Soft Tissue Screw and Washer and MicroMax™ Suture Anchor are used with or without a suture. maintained until healing has occurred. Surgical implants are subject to repeated stresses in use, which can LactoSorb® L-15 Screw Anchors consist of a screw and head design and are used with a suture. The devices result in fracture or damage to the implant. Factors such as the patient’s activity level and adherence to are implanted into a predrilled bone hole and are made of a resorbable copolymer, a polyester derivative of weight bearing or load bearing instructions have an affect on the service life of the implant. The surgeon lactic acid and glycolic acid. Polylactic/polyglycolic acid copolymer degrades and resorbs in vivo by hydroly- must be thoroughly knowledgeable not only in the medical and surgical aspects of the implant, but also sis to lactic and glycolic acids, which are then metabolized by the body. must be aware of the mechanical and polymeric aspects of the surgical implants. MATERIALS 1. Correct selection of the implant is extremely important. The potential for success in soft tissue to bone Poly-L-Lactic Acid/Polyglycolic Acid fixation is increased by the selection of the proper type of implant. While proper selection can help Ultra-High Molecular Weight Polyethylene (UHMWPE) minimize risks, the device is not designed to withstand the unsupported stress of full weight bearing, Polyester load bearing or excessive activity. Polypropylene 2. The implants can loosen or be damaged when subjected to increased loading associated with inadequate healing. If healing is delayed, or does not occur, the implant or the procedure may fail. Loads INDICATIONS produced by weight bearing and activity levels may dictate the longevity of the implant. 1. LactoScrew® L-15 Screw Anchor (85% PLLA/15% PGA): 3. Inadequate fixation at the time of surgery can increase the risk of loosening and migration of the device Shoulder or tissue supported by the device. Sufficient bone quantity and quality are important for adequate Bankart repair fixation and success of the procedure. Bone quality must be assessed at the time of surgery. Adequate SLAP lesion repair fixation in diseased bone may be more difficult. Patients with poor quality bone, such as osteoporotic Acromio-clavicular separation bone, are at greater risk of device loosening and procedure failure. Rotator cuff repair 4. Care is to be taken to assure adequate soft tissue fixation at the time of surgery. Failure to achieve Capsule repair or capsulolabral reconstruction adequate fixation or improper positioning or placement of the device can contribute to a subsequent Biceps tenodesis undesirable result. Deltoid repair 5. The use of appropriate immobilization and postoperative management is indicated as part of the treat- Wrist/Hand ment until healing has occurred. Scapholunate ligament reconstruction 6. Correct handling of implants is extremely important. Do not modify implants. Do not notch or bend im- Ulnar/radial collateral ligament reconstruction plants. Notches or scratches put in the implant during the course of surgery may contribute to breakage. Ankle/Foot Intraoperative fracture of devices can occur if excessive force (torque) is applied while seating. Lateral stabilization 7. DO NOT USE if there is loss of sterility of the device. Medial stabilization 8. Discard and DO NOT USE opened or damaged devices, and use only devices that are packaged in Achilles tendon repair/reconstruction unopened or undamaged containers. Hallux valgus reconstruction 9. Ensure contact of tissue to bone when implanting. DO NOT OVERTIGHTEN the screw. Structural damage Mid- and forefoot reconstruction to the tissue and implant may occur if the screw is overtightened. Elbow 10. Adequately instruct the patient. Postoperative care is important.
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